Alcohol abuse and anxiety disorder in a college student: clinical case study

Client Description.

The client is a 19-year-old single male who was referred for treatment by his parents who are concerned that his use of alcohol is interfering with his grades in college. The client reportedly had all A grades in high school and had been placed in a program for gifted students. However, he has reportedly flunked out of college in his first year. Following this he was also recently arrested for his second DUI offense, the first offense occurring when he was a senior in high school.

According to his parents, the client was born at full term with no complications occurring in the pregnancy and delivery of the baby. He met all of his developmental milestones ahead of expectation and has experienced no major health issues although his last physical examination was several years ago. He excelled in school and was placed in a program for gifted and talented students. According to his parents the client maintained an A average throughout high school even while being in a more challenging gifted program. He went to college with ambitions to go into chemical engineering, but "flunked out" after his first year, an event totally uncharacteristic of his past. His father is a neurosurgeon and his mother is a research scientist. Family history is significant for anxiety disorders in his father and both grandfathers and possible alcohol abuse in both grandfathers.

In addition, the client and his parents report that he has a history of experiences of anxiety and worry present over a three-year period. His parents report he has always been "high strung," but that he began to display physical signs of anxiety such as (dizziness, palpitations, etc.), cognitive signs (a strong sense of worry over his everyday life issues), and behavioral signs (few social contacts, missing school, etc.) while in high school. The anxiety that the client experiences is not limited to specific or discrete situations and does not appear to consist of panic attacks (although this is also a consideration; American Psychiatric Association [APA], 2000). His parents described him as a "functional alcoholic" and that they were unsure if his drinking behaviors occurred before or after his difficulties with anxiety; however, they do know he was drinking alcohol regularly while he was in high school.

B. Assessment

The client's parents contacted the clinic for treatment for their son for his difficulties with suspected alcohol abuse. Both the client and the client's parents (with the permission of the client) participated in a standard clinical interview process designed to coincide with the diagnostic criteria from the DSM -- IV -- TR for axis I and axis II disorders.

The client agreed to enter treatment for issues with anxiety and substance abuse. Both the client and the therapist discussed the goals of treatment for the client. These included designing a program to manage the client's anxiety, attending AA meetings, and individual therapy and that helping the client control his anxiety and his use of alcohol. In addition, the client expressed a wish to return back to school and later sessions will be devoted to specific issues with college, anxiety, and methods of coping with the pressures of college designed specifically for the client.

C. Measurement.

The client underwent a clinical interview that investigated the presence of any DSM -- IV -- TR axis I or axis II disorders. In addition, the counselor plans to administer the Structural Clinical Interview for the DSM (SCID-1 and SCID-2; First, Spitzer, Gibbons, Williams, & Benjamin, 1996; First, Spitzer, Gibbons, & Williams, 1997) for further clarification and quantification of these issues. The SCID-1 and 2 are semi-structured clinical interviews to determine DSM diagnoses on axis I or axis II. The SCID for the new DSM-5 is not yet available, so the DSM-IV-TR was used in this case. In addition to this data a thorough and complete history will be taken regarding the onset of the client's drinking and onset of his difficulties with anxiety in order to determine as best as possible which one preceded the other. This information will be used to determine the focus of treatment (anxiety or substance abuse). The preliminary results of the clinical interview resulted in the following DSM -- IV -- TR diagnosis:

Axis I: 300.02. Generalized Anxiety Disorder

305.00. Alcohol Abuse

Axis II: V71.09. No diagnosis on Axis II

Axis III: No significant medical issues.

Axis IV: Two DUI arrests; flunked out of college; reports feeling isolated from friends and family.

AXIS V: GAF = 51-55. Symptoms of impaired social and interpersonal relationships. Alcohol Abuse. Severe symptoms of anxiety.

The client agreed to maintain a behavioral journal to document the daily instances where he feels anxious in order to establish a baseline with which to judge the effectiveness of the treatment program for his anxiety. The Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) will be used to monitor the client's level of anxiety over the weeks in treatment ad following treatment. This is a 21-question multiple-choice self-report inventory that measures the severity of an individual's anxiety (Beck et al., 1988). Likewise, the client will also maintain a journal of his drinking behavior in an effort to determine a baseline and to use as a barometer to judge the effectiveness of interventions aimed at his drinking.

H. Data Analysis

Since this is a qualitative study no statistical analyses will be performed. Instead most of the data will be looked at in terms of the descriptions of both the client and his parents regarding his progress, number of drinks consumed, severity of anxiety, and number of episodes of anxiety that occur over the course of treatment. Compliance with AA will be measured by attendance sheets and qualitative information obtained from counseling sessions. Client data will be gathered weekly; data from the parents will be gathered pre -- and post-treatment and at specific post -- treatment follow-up times.

I. Limitations of the Evaluation Study.

There are several limitations to this study:

1. The study only uses a single participant, thus generalizability is limited.

2. The study relies heavily on self-report data which can be unreliable and requires the single participant to be candid.

3. There may be several interventions going on at the same time including treatment for anxiety or substance abuse and AA. It is impossible to tell which treatment(s) are actually being effective here.

4. The study will utilize data from the client and the client's parents and this data may not coincide. Moreover, the parents may not have a realistic view of what is going on with their son.

5. The study cannot determine which disorder came first: GAD or substance abuse. It must rely on the self-report of the client to postulate this relationship. Moreover, the study cannot infer that one disorder caused the other to occur as it is correlational nature.

6. If in the current study it is determined that the client's anxiety disorder preceded the alcohol abuse or vice versa concentrating treatment on one particular disorder and achieving success in both behaviors does not necessarily mean that one disorder preceded or caused the other.

J. Ethical Considerations.

There are four major ethical considerations to consider here (Pope & Vasquez, 2010):

1. Getting Informed Consent. Getting informed consent from clients for therapy and a research study is of fundamental importance as it assures the client's independence in entering and following the guidelines of counseling and research as well as informing them of the procedures including roles, rights and responsibilities of all parties involved.

2. Counselor Competence. Counselors have an ethical responsibility only to practice within the scope of their professional competence as judged by education, training, and experience. Moreover, counselors should base treatments on established methods backed by sound theory. The counselor should be able to describe the theoretical basis for providing a counseling service or using a particular method. In this vein is also important for the counselor to make sure that all issues of concern are subject to treatment during the intervention (e.g., both the substance abuse and the anxiety and any other issues).

3. Confidentiality. Counselors need to carefully guard against the unauthorized disclosure of client information. This issue should be explained to the client and his parents.

4. The maintenance of appropriate boundaries during the sessions and afterwards should be discussed with all parties.

K. Directions and Recommendations for Future Practice Evaluation Studies.

In order to answer the questions regarding whether one disorder triggers another it may be prudent to use large sample research, standardized measures to investigate the onset of the disorders, corroboration from significant others, and more advanced statistical analyses such as structural equation modeling, path analysis, etc. (Tabachnick & Fidell, 2012). In addition, it may be the severity of the symptoms of one particular disorder such as an anxiety disorder that leads to later substance abuse as opposed to its mere presence. These are the types of research hypotheses that are best answered with larger sample sizes and quantitative data or mixed research designs. The question of cause and effect requires experimental designs (Tabachnick & Fidell, 2012).

Likewise, research that is intended to investigate the effectiveness of concentrating on the treatment of one comorbid disorder in order to determine if improvement in the one disorder will result in improvement in other comorbid disorders would require larger sample sizes. However, this last question might raise several ethical issues and such research may not be approved by human subjects research review boards. Certainly any competent counselor would want to address all the issues as directly as possible and not leave the door open for issues not to be addressed in counseling.